1. Field of the Invention
The invention relates to the field of healthcare claims and to systems and methods to improve loss control in payment of claims.
2. Description of the Related Art
When an insured patient receives medical services and/or products from a health care provider, a health care claim typically results for reimbursement/payment of charges associated with the health care services. A health care claim frequently undergoes some type of internal processing by a payer, such as a health care insurance company. Once the processing is completed, the claim is forwarded for payment. Governmental regulations applying to the health care insurance industry generally require that claims be processed and paid as indicated in a timely manner.
A troublesome aspect of the health care field is that a disproportionately large fraction of the costs incurred are attributable to a disproportionately small fraction of the insured population. This phenomena is at least partly to be expected as a majority of people are relatively healthy and injury-free for a large fraction of their life and thus would not be expected to incur significant medical costs. However, there are non-negligible unwarranted costs associated with at least some health care claims. For example, honest mistakes and misunderstanding of proper formulation of a health care claim can result in unwarranted, inflated costs associated with the claim. In addition, incidents arise of intentional abuse and/or fraud of the health care provision and payment system. For example, a provider can duplicate bill for the same service provided, over bill for the number of units provided, and/or conduct excessive testing beyond that which would be considered medically necessary for the given case.